Lid/Orbit
Herpes Zoster Ophthalmicus
Also known as: HZO, shingles eye, ophthalmic shingles, V1 shingles, zoster ophthalmicus, herpes zoster eye, Hutchinson sign, shingles around eye
Filed as: Urgent
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
A broader V1 varicella-zoster reactivation syndrome involving the forehead, periocular skin, eyelids, conjunctiva, and potentially deeper ocular structures. This parent record is for the acute unilateral dermatomal rash or pain pattern and ocular-risk triage; herpes zoster keratitis remains the separate cornea-specific manifestation. The safety task is to identify HZO early, check for ocular involvement, arrange prompt medical/ophthalmology care, and escalate immediately for corneal disease, uveitis, raised IOP, reduced vision, orbital signs, immunosuppression, or diagnostic uncertainty.
Recognition
Symptoms: what patients report
- Acute unilateral forehead, scalp, brow, upper-lid, or periocular pain, burning, tingling, or skin sensitivity.
- Vesicular rash in the ophthalmic division of the trigeminal nerve, often involving forehead, upper eyelid, or periocular skin.
- Eyelid swelling, tenderness, crusting, or periocular redness on the affected side.
- Watery red eye, conjunctival irritation, or foreign-body sensation may be present.
- Photophobia, blurred vision, or deeper ocular pain suggests ocular involvement rather than skin-only disease.
- Systemic symptoms such as malaise, headache, or fever may accompany acute zoster.
Signs: what the examination shows
- Unilateral dermatomal vesicles, erosions, or crusting in the V1 distribution.
- Hutchinson sign: vesicles or crusting on the tip, side, or root of the nose, indicating nasociliary involvement and higher ocular-risk.
- Upper-lid oedema, periocular erythema, lid vesicles, or lid crusting on the affected side.
- Conjunctival injection, chemosis, episcleritis, or scleritis may occur.
- Corneal involvement may include punctate epithelial keratitis, pseudodendrites, stromal keratitis, reduced corneal sensation, or neurotrophic keratopathy.
- Anterior uveitis, raised IOP, sectoral iris changes, or keratic precipitates may indicate herpetic uveitis/keratouveitis.
- No proptosis, restricted eye movement, RAPD, or reduced motility in uncomplicated periocular HZO.
What OptoGuide™ covers for herpes zoster ophthalmicus
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked Australian therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Herpes Zoster Ophthalmicus - EyeWiki
- Herpes Zoster Ophthalmicus - StatPearls - NCBI Bookshelf
- Herpes Zoster Ophthalmicus - Merck Manual Professional Edition
- Anterior Eye Disease and Therapeutics A-Z (Bruce & Loughnan) — standard reference text
- Case 12-2021: A 78-Year-Old Man with a Rash on the Scalp and Face. Yoon MK, Kelly HR, Freitag SK, et al. The New England Journal of Medicine. 2021;384(16):1553-1562.
- Distinguishing Features of Anterior Uveitis Caused by Herpes Simplex Virus, Varicella-Zoster Virus, and Cytomegalovirus. Terada Y, Kaburaki T, Takase H, et al. American Journal of Ophthalmology. 2021;227:191-200.
- Approach to Eye Pain: Differential Diagnosis and Work Up for the Neurologist. Robblee J, Patel JN. Current Neurology and Neuroscience Reports. 2025;25(1):48.
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, The Wills Eye Manual, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.